The Ombudsman's final decision:
Summary: There is no fault in the actions of Dorset Healthcare University NHS Foundation Trust (DHC). It was not aware of Mr Y and made no decisions about his support needs. The Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust’s (RBC) professional opinion was that Mr Y did not meet the criteria for intermediate care. There is no fault in its decision making. Mr Y did not meet the criteria for the Council’s reablement service.
- The complainant, whom I refer to as Mr Y, complains that he was not provided with intermediate care services free of charge following a hip operation at Bournemouth hospital. This is a joint complaint involving:-
- RBC who carried out the operation;
- DHC who manages the Poole Intermediate Care Service (PICS), and includes a small number of social care staff; and,
- the Council who is responsible for Short Term Assessment, Reablement and Telecare (START) services and the Council who Mr Y says has the over-riding statutory duty to provide intermediate care services under the Care Act 2014.
- there were flaws in the lack of referral to PICS at the outset;
- PICS did not properly consider the request for a fee refund;
- PICS eligibility criteria is flawed as it says that people are not entitled to support if they have elective surgery as their needs are foreseeable;
- The Council had a duty to provide appropriate intermediate care services even if he did not fit the criteria of the local schemes for START and PICS.
The Ombudsmen’s role and powers
- The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
- If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
- The Ombudsmen cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant organisation has to make. Therefore, my investigation has focused on the way that the body made its decision.
How I considered this complaint
- I spoke with Mr Y and considered information that he provided. I made enquiries of the Trusts and the Council and considered their responses.
What I found
- Mr Y lives alone and has lymphoedema ( a long term condition that causes swelling in the body’s tissues) in his left leg. Mr Y needs to wear a compression stocking on his left leg during the day. He puts on the compression stocking in the morning and takes it off in the evening. He then washes, dries and creams his leg in the evening so that the cream has time to dry during the night before the stocking is reapplied the following morning.
- Mr Y had a full pre-operative assessment at the hospital followed, some weeks later, by a home visit from an Occupational Therapist (OT) who suggested various aids for, and use, in the home for the first few weeks after he was discharged from hospital following the hip operation.
- The hospital advised Mr Y that after his operation he should not bend further than his knee for between six weeks and three months. The OT said that hospital staff would assess Mr Y following his operation to see if there were any services he needed when he left hospital.
- Mr Y had the hip operation. During the operation his right thigh bone became fractured. Medical staff and the OT told Mr Y that they would be imposing weight bearing and movement restrictions on the use of his right leg. This would affect Mr Y’s mobility for at least six weeks and up to three months.
- The Council assessed Mr Y as needing help with washing, drying and creaming his leg; putting on and taking off the compression stocking; the preparation of meals and drinks and maintaining his living environment. The Council completed a care assessment and support plan which identified that Mr Y was eligible for services. Mr Y says that the Council told him he would have to pay for services because he had opted to have elected surgery.
- The Council says that Mr Y declined to have a financial assessment and that he was insistent that he should not have to pay for services. As a result of this it made a referral to the START team.
- The Council said that Mr Y did not meet the criteria for the START service. This was because Mr Y’s movement was restricted and he would not achieve reablement goals.
- In order to leave hospital Mr Y privately bought care from a home care agency on the basis of the support plan the Council had compiled.
- Although Mr Y asked a number of different Council staff whilst he was still in hospital, it was only when he made a written request for explanations of why he did not receive free Intermediate Care Services, following his discharge from hospital, that he did finally get such written explanations some 10 weeks later on 12 April 2016. Mr Y then made a formal complaint six weeks later. The written explanations of 12 April were three months from the day of his operation and two and half months from his written request.
- RBC describes PICS as,
“an intermediate care service for all adults over the age of 18 who are registered with a Bournemouth and Poole GP, which will undertake acute assessment and diagnosis, crisis and rapid support, intensive rehabilitation/reablement and treatments for adults and older people”.
- The Council took advice from PICS, a team leader told the Council that it would not provide an intermediate care service where people have had “elective” surgery. This is because in its view people should arrange support for when they leave hospital. The team leader says that the pre-operative assessment is an opportunity for the person to establish what the likely outcomes of the surgery are and what services they might need to arrange when they leave hospital. This includes asking friends or family to help or arranging and funding private care.
- DHC says it did not receive a referral for Mr Y from ward staff. It told the Council however that it would not have provided support to Mr Y. This is because it says that the fracture to his thigh bone was a foreseeable result of the hip replacement as it is common. Mr Y could therefore have planned for services to meet his needs following the surgery. I have however been unable to find this included in DHC’s written criteria. In addition in response to my enquiries RBC do not appear to agree with this. It says that,
“Both the PICS and START services are managed on a “needs” basis and it is our understanding that no person is exempt regardless of whether their need is as a result of elective care or emergency care”.
- RBC says that it did not refer Mr Y for intermediate care as he did not meet the criteria for support. This is because:-
- he was aware and understood the risks associated with having the operation and the support he might need after the operation;
- he had no health or reablement needs on discharge from the hospital. Both physiotherapist and occupational therapists were involved with Mr Y until his discharge from hospital and did not identify any intermediate or reablement needs;
- his only needs were basic social care needs.
What should have happened
- Section 2 Care Act 2014, “Preventing needs for care and support” says that councils should provide services which it considers will This section has no associated Explanatory Notes
“contribute towards preventing or delaying the development by adults in its area of needs for care and support........reduce the needs for care and support of adults in its area”.
- The Care and Support statutory guidance that accompanies the Care Act 2014 says;
“ 2.12 There is a tendency for the terms ‘reablement’, ‘rehabilitation’ and ‘intermediate care’ to be used interchangeably. The National Audit of Intermediate Care categorises 4 types of intermediate care:
- crisis response – services providing short-term care (up to 48 hours)
- home-based intermediate care – services provided to people in their own homes by a team with different specialities but mainly health professionals such as nurses and therapists
- bed-based intermediate care – services delivered away from home, for example, in a community hospital
- reablement – services to help people live independently which are provided in the person’s own home by a team of mainly care and support professionals
2.13 The term ‘rehabilitation’ is sometimes used to describe a particular type of service designed to help a person regain or re-learn some capabilities where these capabilities have been lost due to illness or disease. Rehabilitation services can include provisions that help people attain independence and remain or return to their home and participate in their community, for example independent living skills and mobility training for people with visual impairment.
2.14 ‘Intermediate care’ services are provided to people, usually older people, after they have left hospital or when they are at risk of being sent to hospital. Intermediate care is a programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live independently – as such they provide a link between places such as hospitals and people’s homes, and between different areas of the health and care and support system – community services, hospitals, GPs and care and support.
2.15 To prevent needs emerging across health and care, integrated services should draw on a mixture of qualified health, care and support staff, working collaboratively to deliver prevention. This could involve, for instance, reaching beyond traditional health or care interventions to help people develop or regain the skills of independent living and active involvement in their local community.....
2.55 Preventative services, like other forms of care and support, are not always provided free, and charging for some services is vital to ensure affordability. The Care and Support (Preventing Needs for Care and Support) Regulations 2014 continue to allow local authorities to make a charge for the provision of certain preventative services, facilities or resources. The regulations also provide that some other specified services must be provided free of charge........
2.60 The regulations require that intermediate care and reablement must be provided free of charge for up to 6 weeks, as must aids and minor adaptations (for example: adaptations up to the value of £1,000) (see also 8.14).”
- The Care and Support (Preventing Needs for Care and Support) Regulations 2014 say,
“2.61 Where local authorities provide intermediate care or reablement to those who require it, this must be provided free of charge for a period of up to 6 weeks. This is for all adults, irrespective of whether they have eligible needs for ongoing care and support. Although such types of support will usually be provided as a preventative measure under section 2 of the Act, they may also be provided as part of a package of care and support to meet eligible needs. In these cases, regulations also provide that intermediate care or reablement cannot be charged for in the first 6 weeks, to ensure consistency.
2.62 Whilst they are both time-limited interventions, neither intermediate care nor reablement should have a strict time limit, since the period of time for which the support is provided should depend on the needs and outcomes of the individual. In some cases, for instance a period of rehabilitation for a visually impaired person (a specific form of reablement) 2, may be expected to last longer than 6 weeks. Whilst the local authority does have the power to charge for this where it is provided beyond 6 weeks, local authorities should consider continuing to provide it free of charge beyond 6 weeks in view of the clear preventative benefits to the individual and, in many cases, the reduced risk of hospital admissions.
2.63 Local authorities should consider the potential impact and consequences of ending the provision of preventative services. Poorly considered exit strategies can negate the positive outcomes of preventative services, facilities or resources, and ongoing low-level care and support can have significant impact on preventing, reducing and delaying need.”
- The Council provides some intermediate care services. This is usually provided to people leaving hospital to assist them to live independently and to avoid blocking beds in hospital.
- The eligibility for intermediate care in Poole says:-
- “Patient is aged 18 or over and is currently registered with a GP in the Poole locality;
- The referred patient has acute health needs requiring the input of the multidisciplinary team to avoid an unnecessary admission to an acute hospital (for example supporting the GP to manage their acutely unwell patients in the community, consultant review, and rapid intervention to achieve clinical stability);
- The referred patient requires short term input for acute needs with a multi-disciplinary approach to support an early discharge from hospital.”
“Considered to have the potential to make progress with learning and/or re-learning skills within a short period of time following an acute episode or illness”
- The Council’s criteria says that it is not suitable for people who have:-
- hoisting needs,
- an existing package of care;
- nursing or therapy needs.
- Non-weight bearing
- Have a plaster of Paris
- Only require assistance with compression stockings.
“Acute care closer to home/intermediate care services should be regarded as the provision of integrated services within the community to promote faster recovery from illness, prevent unnecessary acute hospital admissions, support timely discharge and maximise independent living and is delivered in a patient’s own home or non acute setting.......that would meet all of the following criteria:
- Are targeted at people who would otherwise face unnecessary prolonged hospital stays or inappropriate admission to acute in-patient care or long-term care.
- Are provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves opportunity for recovery.
- Have a planned outcome of maximising independence and typically enabling patients/users to resume living at home.
- Is time limited, normally no longer than six weeks and frequently as little as 1 – 2 weeks or less (for reablement this can be longer)
- Involve partnership working, with a single assessment framework”
Is there fault causing injustice?
The Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust’s (RBC)
- I have considered the records that RBC provided and its response to my enquiries and I am unable to find fault in its actions.
- Mr Y did not have intermediate care needs. He was weight bearing although this was restricted to 50% in his right leg; and able to manage most tasks unaided. He had no reablement goals and did not need any health intervention. He therefore did not meet the criteria as set out in CASS or RBC’s criteria for intermediate care, both described above. I am therefore unable to say that RBC should have referred Mr Y for intermediate care.
Dorset Healthcare University NHS Foundation Trust (DHC)
- Mr Y complains about PICS and its criteria. PICS however never received a referral for Mr Y and the policy was therefore never applied. I am therefore unable to criticise DHC for a decision that it had no involvement in.
- However I am concerned that DHC have an unwritten policy that prevents people from accessing PICS if they have elective surgery. This seems at odds with responses from both the Council and RBC. It also seems to be contrary to CASS which provides no distinction between elective and non-elective surgery.
- While this did not affect Mr Y’s access, as he would still not have been entitled to PICS, for the reasons set out above, it would affect other people. I therefore strongly suggest that DHC discusses this with the partnership organisations and amends their policy accordingly. DHC should also remind staff that there is no distinction between elective and non-elective surgery and that all patients have the same criteria for access to intermediate care services regardless of the type of surgery that they have.
Poole Borough Council
- I find no fault in the Council’s decision not to provide Mr Y with reablement services. This is because Mr Y had restricted movement in his right leg which meant that he would not be able to meet reablement goals. He was therefore not eligible for reablement services.
- The Council has however been unclear throughout Mr Y’s complaint about who was responsible for certain decisions which has caused some confusion. Although the Council did engage with DHC this was on a piecemeal basis without proper consideration of what the complaint was. I consider that this falls short of the duty to cooperate included in the complaints regulations.
- Mr Y spent time and effort in trying to understand why he was not entitled to intermediate care. The failure to provide him with clear information prevented him from being able to properly understand why he was refused free care and make relevant representations as part of his complaint.
- The Council failed to provide Mr Y with clear information as part of its complaint handling. This caused Mr Y time, effort and confusion when dealing with his complaint. I therefore consider that within one month of the final decision it should apologise to Mr Y and make a payment to him of £150 for his time, trouble and frustration in progressing his complaint.
- I do not uphold the complaint that Mr Y was entitled to free intermediate or reablement services. However the Council failed to provide him with relevant information for him to effectively deal with his complaint.
- I have completed my investigation and closed the complaint on the basis of the agreed action above.
Investigator's decision on behalf of the Ombudsman